• CONFIDENTIAL HEALTH INFORMATION

  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you consulted a chiropractor before?
  • Birth Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender
  • Marital Status
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • May we contact you at work?
  • Preferred method of contact?
  • Birth Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Who carries this policy?
  • Format: (000) 000-0000.
  • 2. And are the result of:
  • An accident or injury
  • 5. Duration and Timing (When did it start and how often do you feel it?)
  • 6. Quality of Symptoms (What does it feel like?)
  • 7. Location (Where does it hurt?) Circle the area(s) on the illustration. "O" for current condition, and "X" for conditions experienced in the past.

  • 9. Aggravating or relieving factors (What makes it better or worse, such as time of day, movements, certain activities, etc.)

  • 10. Prior interventions (What have you done to relieve the symptoms?)

  • 12. How does your current condition interfere with your:

  • 13. Review of Systems

    Chiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. Please select beside any condition that you've Had or currently Have and initial to the right.

  • a. Musculoskeletal
    Rows

  •          

  • b. Neurological
    Rows

  •          

  • c. Cardiovascular
    Rows

  •          

  • d. Respiratory
    Rows

  •          

  • e. Digestive
    Rows

  •          

  • f. Sensory
    Rows

  •          

  • g. Skin
    Rows

  •          

  • h. Endocrine
    Rows

  •          

  • i. Genitourinary
    Rows

  •          

  • j. Constitutional
    Rows

  •          

  • Past Personal, Family and Social History

    Please identify your past health history, including accidents, injuries, illnesses and treatments. Please complete each section fully.

  • 14. Illnesses

  • Check the illnesses you have HAD in the past or HAVE now.
    Rows

  • 15. Operations

  • Check the ones you've received in the Past or are receiving Currently.
    Rows

  • 17. Allergies

  • Are you allergic to my medications?

  • 18. Injuries

  • Have you ever...

  • 19. Family History

    Some health issues are hereditary. Tell Dr. Wolf-Richter about the health of your immediate family members.
  • Relative
    Rows

  • 21. Social History

    Tell Dr. Wolf-Richter about your health habits and stress levels.
  • SOCIAL
    Rows
  • Prayer or meditation?
  • Job pressure/ stress?
  • Financial peace?
  • Vaccinated?
  • Mercury filings?
  • Recreational drugs?

  • 22. Activities of Daily Living

  • How does this condition currently interfere with your life and ability to function?
    Rows
  • 27. Describe your typical eating habits:

  • Acknowledgements

  • To set clear expectations, improve communications and help you get the best results in the shortest amount of time, please read each statement and initial your agreement.

     I instruct the chiropractor to deliver the care that, in his or her professional judgement, can best help me in the restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art from medicine and does not proclaim to cure any named disease or entity.

    I may request a copy of the Privacy Policy and understand it describes how my personal health information is protected and released on my behalf for seeking reimbursement from any involved third parties.

    I realize that an X-ray examination may be hazardous to an unborn child and I certify that to
    the best of my knowledge I am not pregnant. Date of last menstrual period: Pick a Date   

    I grant permission lo be called and texted lo confirm or reschedule an appointment and lo be sent occasional cards, letters, emails or health information lo me as an extension of my care in this office.

    I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services I receive.

    To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern.

  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: